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Abstract

The mechanical properties of the female pelvic floor are important to understanding pelvic diseases. These diseases can be connected with a variety of risk factors, including hormonal changes, vaginal birth, and obesity, all of which have an impact on mechanical response. The PFM are the body's only transverse load-bearing muscle group, supporting the abdominal and pelvic organs. Dual role of supplying stability in the lumbopelvic area.

PFM diseases, such as urinary incontinence, non-obstructive urine retention, painful bladder syndrome, fecal incontinence, persistent constipation, and sexual dysfunction, pose a number of obstacles for treating physicians. PFM are also part of a much larger skeletal system known as the abdominal core, which works in tandem with the diaphragm, lower back, and abdominal wall muscles to influence spinal stability, spinal alignment, and respiration. The PFM links to several of the thigh muscles and is thus stimulated while walking, running, and performing various other dynamic movements. 

Keywords

 low back pain, female pelvic floor dysfunction, lumbopelvic stability

Introduction

The superficial and deep PFM provide a variety of roles in the musculoskeletal as well as other systems, including the urinary, gastrointestinal, sexual, and respiratory. They help to regulate intra abdominal pressure [1] and breathing [2], play a role in sacroiliac joint support [3], pelvic and lumbar spine equilibrium, act as a postural stabilizer to aid in core stability [2], contribute to sexual activity [4], and act as a support system for continence maintenance and prolapse of pelvic organs prevention [5,6]. PFM dysfunction has lately been linked to the onset of Low Back Pain (LBP). Research suggests a relationship between LBP and PFD.

PFM dysfunction can be classified as pelvic pain syndromes, voiding/defecatory problems (urinary incontinence, anal/FI, retention, urgency), constipation, POP, and sexual dysfunction. The PFM are the body's only transverse load-bearing muscle group, and they support the abdominal and pelvic organs. The dual purpose of providing stability in the lumbo-pelvic area. PFM has been postulated to help regulate the lumbar spine by contributing to intra-abdominal pressure (and consequently fascial tension) and pelvic stability via strengthening the sacroiliac joints [7]. PFD is an umbrella term that refers to a wide range of clinical problems, including bowel and bladder incontinence, pelvic organ prolapse, sexual dysfunction, and chronic pain syndromes involving the pelvic tissues and musculature [8-10] Figure 1, Figure 2.

Figure 1 & Figure 2. Pelvic floor muscles

Figure 3. Sacrum mobility with PFM

Kinesiology and muscle physiology research have shown that LBP can develop as a result of changes in control of the conventional trunk muscles (transversusabdominis, rectus abdominis, and multifidus); more recent research has recognized the role of the PFMin spinal stability [11,12].
Co-activation of the PFMs and abdominal muscles improves spinal stability by hardening the spinal column and raising intraabdominal pressure. It is probable that a lack of PFM activity affects the neuromuscular link between the PFMs and the abdominal muscles, resulting in a disruption in muscle synergy [13]. So, the goal of this review is to highlight the excessive link between LBP and PFD.

Literature Review

Low back pain and urine incontinence have been linked in major epidemiological studies, and having symptoms of one appears to predispose to the development of the other. There is insufficient data to show that pelvic floor therapies are beneficial for LBP in this patient population; thus, the mechanism underlying this link is still unknown [14].

During clinical practice, we have seen patients with temporally linked low back pain and urine symptoms; however, no relevant neurological disorders have been discovered during neurological consultation or spinal imaging. Sometimes it occurs as a result of an acute low back injury, while other times the urine and back pain symptoms develop gradually. Previous research has revealed a relationship between LBP and PFD [15,16].

Cadaveric investigations have shown that greater pelvic floor tension stabilizes the sacroiliac joint, aligns the sacrum, and enhances the lumbar spine and pelvis' ability to withstand physical stress [7].
Vleeming, et al. [17] illustrate how the pelvic girdle's ligaments, fascia, and muscles contribute to SI joint stability. Force closure, along with the intrinsic bony congruency of the SI joint surface, provides maximum SI joint stability. Pool-Goudzwaard, et al. [7] conducted a biomechanical investigation on 18 cadaveric specimens (9 males and 9 females) and found that simulated strain on pelvic floor muscles increased stiffness across the SI joints. The authors hypothesized that greater pelvic floor muscle activation may occur in individuals with SI joint dysfunction in an attempt to reestablish load transmission via the lumbopelvic region. It should be noted that the specimens were of an average age of 77 years (SD 14.4), and therefore, this biomechanical relationship may differ in younger patients. [7].

The levatorani muscle is a fiber-reinforced muscle of the skeleton located between the pubic bone at the front and the coccyx at the back [18]. To better understand the mechanical features of the PFM in various diseases, the first step is to correctly duplicate the female pelvic anatomy-the levatorani and surrounding tissues (coccyx, obturator muscles, and symphysis pubis [19]. The sacrococcygeal joint is formed when the sacrum's apex and the initial coccyx segment connect. There is a sacrococcygeal fibrocartilage disc, commonly known as the interosseus ligament. The sacrococcygeal joint has a normal range of 15° flexion and 13° extension. In normal physiological movement, when the sacrum extends the top of the coccyx moves anteriorly or flexes, and as the sacrum flexes, the top goes posteriorly or extends. The sacrum consists of five fused segments, while the coccyx is made up of five joined primitive bones. The interosseous, dorsal, and anterior sacroiliac ligaments all work together to keep the sacroiliac joints stable. Other auxiliary ligaments, such as the iliolumbar, stabilize the upper half of the joint, while the sacrospinous and sacrotuberous stabilize the lower part of the sacrum. The anococcygeal ligament, located at the distal end of the coccyx, connects the rectoanal angle, levatorani, and pelvic organs [20,21] Figure 3.

These diseases may result from changes in the mechanical characteristics of supporting structures caused by muscle or ligament damage or alterations in the elasticity of the pelvic fascia and bone associated with the previously mentioned risk factors [22]. Abnormalities in the pelvic ligaments and fascia may be related to reduce total collagen and elastin [23].

Large epidemiological studies have linked LBP with PFD, and having symptoms of one appears to promote the patient's development of the other.

The lumbopelvic-hip complex contributes to the formation of the core. The diaphragm, PFM and hip complex, abdominals, spine, and gluteal muscles are all included in the three-dimensional box or canister known as the core. Although there are multiple global (bigger, longer) and local (smaller, shorter) muscles involved in core stability [24,25], variations in core muscle activity during FSD utilizing non-invasive medical imaging may assist doctors better assess lumber angle and pelvic tilt[26,27]. PFM exercise is beneficial to sexual activity and quality of life [28].

Conclusion

Physiotherapy, including the pelvic floor rehabilitation, should be a helpful intervention when these conditions coexist. Women with PFD may have increased LBP. PFM strength and diaphragm excursion in females should be taken into consideration in LBP associated with PFD, which helps the therapist in therapeutic decisions and may be useful in developing guidelines for treating PFD.

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Conflicts of Interest

No conflicts of interest are present.

Ethical Statement

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Consent Statement

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Data Availability

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References

1. Hemborg B, Moritz U, Lowing H (1985) Intra-abdominal pressure and trunk muscle activity during lifting. Scand J Rehabil Med 17: 25-38. [Crossref]
2. Hodges PW, Sapsford R, Pengel LH (2007) Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn 26: 362-371. [Crossref]
3. Shafi k A (2000) The role of the levatorani muscle in evacuation, sexual performance and pelvic floor disorders. Int Urogynecol J Pelvic Floor Dysfunct 11: 361-376. [Crossref]
4. Rosenbaum TY (2007) Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment: a literature review. J Sex Med 4: 4-13. [Crossref]
5. Wei JT, DeLancey JO (2004) Functional anatomy of the pelvic floor and lower urinary tract. Clin Obstet Gynecol 47: 3-17. [Crossref]
6. Herschorn S (2004) Female pelvic floor anatomy: the pelvic floor, supporting structures, and pelvic organs. Rev Urol 6 Suppl 5(Suppl 5): S2-S10.
7. Pool-Goudzwaard A, van Dijke GH, van Gurp M, Mulder P, Snijders C, et al.  (2004) Contribution of pelvic floor muscles to stiffness of the pelvic ring. Clin Biomech 19: 564-571. [Crossref]
8. Sung VW, Hampton BS (2009) Epidemiology of pelvic floor dysfunction. Obstet Gynecol Clin North Am 36: 421-443. [Crossref]
9. Grigorescu BA, Lazarou G, Olson TR, Downie SA, Powers K. et al. (2008) Innervation of the levatorani muscles: description of the nerve branches to the pubococcygeus, iliococcygeus, and puborectalis muscles. Int Urogynecol J Pelvic Floor Dysfunct19: 107-116. [Crossref]
10. Petros P (2010) Pelvic Floor Rehabilitation according to the Integral Theory Towards a more time efficient method for pelvic floor rehabilitation and with a wider symptom scope. In: The Female Pelvic Floor. Springer, Berlin, Heidelberg.
11. Grewar H, McLean L (2008) The integrated continence system: a manual therapy approach to the treatment of stress urinary incontinence. Man Ther 13: 375-386. [Crossref]
12. Hodges PW, Sapsford R, Pengel LHM (2007) Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn 26: 362-371. [Crossref]
13. Pereira LC, Botelho S, Marques J, Amorim CF, Lanza AH, et al. (2013) Are transversusabdominis/oblique internal and pelvic floor muscles coactivated during pregnancy and postpartum. Neurourol Urodyn 32: 416-419. [Crossref]
14. Welk B, Baverstock R (2020) Is there a link between back pain and urinary symptoms? Neurourol Urodyn 39: 523-532. [Crossref]
15. Kim H, Yoshida H, Hu X, Saito K, Yoshida Y, et al. (2015) Association between self‐reported urinary incontinence and musculoskeletal conditions in community‐dwelling elderly women: a cross‐sectional study. Neurourol Urodyn 34: 322-326.
16. Bush HM, Pagorek S, Kuperstein J, Guo J, Ballert KN, et al. (2013) The association of chronic back pain and stress urinary incontinence: a cross-sectional study. J Womens Health Phys Therap 37: 11-18. [Crossref]
17. Vleeming A, Stoeckart R, Volkers AC, Snijders CJ (1990) Relation between form and function in the sacroiliac joint. Part I: clinical anatomical aspects. Spine (Phila Pa 1976) 15: 130-132.
18. Noakes KF, Pullan AJ, Bissett IP, Cheng LK (2008) Subject specific finite elasticity simulations of the pelvic floor. J Biomech 41: 3060-3065. [Crossref]
19. Janda S (2006) Biomechanics of the pelvic floor musculature. PhD. Thesis. Technische Universiteit Delft, Netherlands.
20. Morrison P (2016) Musculoskeletal Conditions Related to Pelvic Floor Muscle Overactivity. In: Padoa, A., Rosenbaum, T (eds) The Overactive Pelvic Floor. Springer, Cham.
21. Weiselfish Giammatteo S, Giammatteo T (2003) Integrative manual therapy for biomechanics, application of muscle energy and beyond technique: treatment of the Spine, Ribs, and Extremities. Berkeley: North Atlantic Books 225-228.
22. Abramowitch SD, Feola A, Jallah Z, Maolli PA (2009) Tissue mechanics, animal models, and pelvic organ prolapse: a review. Eur J Obstet Gynecol Reprod Biol 144: S146-S158. [Crossref]
23. Chen B, Yeh J (2011) Alterations in connective tissue metabolism in stress incontinence and prolapse. J Urol 186: 1768-1772. [Crossref]
24. Warren L, Nasypan A (2014) Core concepts: understanding the complexity of the spinal stabilizing systems in local and global injury prevention and treatment. IJATT 19: 28-33.
25. Colston M (2012) Core Stability, part 1: overview of the concept. IJATT 17: 8-13.
26. Abdel Hady DA, El-Hafeez TA (2024) Revolutionizing core muscle analysis in female sexual dysfunction based on machine learning. Sci Rep 14: 4795. [Crossref]
27. Hady A, Doaa A, El-Hafeez TA (2023) Predicting female pelvic tilt and lumbar angle using machine learning in case of urinary incontinence and sexual dysfunction. Sci Rep 13: 17940. [Crossref]
28. Hady DAA, Kassem ARE, Abdalla HA (2024) Effect of knack technique on vaginal laxity in multiparous women: A randomized controlled trial. Physiother Res Int 29: e2036. [Crossref]